Provider Demographics
NPI:1083628556
Name:MILLER, GERALD WENDAL (MD,)
Entity Type:Individual
Prefix:DR
First Name:GERALD
Middle Name:WENDAL
Last Name:MILLER
Suffix:
Gender:M
Credentials:MD,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1960 NW 167TH PLACE
Mailing Address - Street 2:SUITE 103
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97006
Mailing Address - Country:US
Mailing Address - Phone:503-466-1823
Mailing Address - Fax:503-466-1823
Practice Address - Street 1:1960 NW 167TH PLACE
Practice Address - Street 2:SUITE 103
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97006
Practice Address - Country:US
Practice Address - Phone:503-466-1823
Practice Address - Fax:503-466-1823
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR16819207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine